Gallstones

Topic Overview

What are the gallbladder and gallstones?

The
gallbladder is a small sac found just under the liver.
It stores
bile made by the liver. Bile helps you digest fats.
Bile moves from the gallbladder to the
small intestine through tubes called the cystic duct
and common bile duct.

Gallstones are made from
cholesterol and other things found in the bile. They
can be smaller than a grain of sand or as large as a golf ball.

Most gallstones do not cause problems. But if they block a duct, they
usually need treatment.

What causes gallstones?

Gallstones form when
cholesterol and other things found in bile make stones. They can also form if
the gallbladder does not empty as it should. People who are overweight or who
are trying to lose weight quickly are more likely to get gallstones.

What are the symptoms?

Most people who have
gallstones do not have symptoms.

If you have symptoms, you most
likely will have mild pain in the pit of your stomach or in the upper right
part of your belly. Pain may spread to your right upper back or shoulder blade
area. Sometimes the pain is more severe. It may be steady, or it may come and
go. Or it may get worse when you eat.

When gallstones keep blocking a
bile duct, you may have pain with fever and chills. Or your skin or the
whites of your eyes may turn yellow. Call your doctor right away. Having stones
in your bile duct increases your chance of having a swollen
pancreas (pancreatitis).
These symptoms may also be a sign of an infected gallbladder.

Call your doctor right away if you have sudden or bad pain in your belly or
chest and you are not sure what is causing it. Symptoms of gallstones may feel
like chest pain caused by a heart attack or other serious problems.

How are gallstones diagnosed?

You may decide to go to the
doctor because of pain in your belly. In this case, your doctor will ask you
questions about when the pain started, where it is, and if it comes and goes or
is always there. Your doctor may order
imaging tests. These take pictures of the inside of
your body. An
ultrasound of the belly is the best test to find
gallstones. This test does not hurt.

Your ultrasound may not show
gallstones. But if your doctor still thinks you have a problem with your
gallbladder, he or she may order a gallbladder scan. In this test, a doctor
injects dye into a vein in your arm. Then a machine takes
X-rays as the dye moves through your liver, bile duct,
gallbladder, and intestine.

Most people have gallstones but don't know it because they do not have symptoms. Gallstones may be found by
accident when you have tests for other health problems or when a woman has an
ultrasound during pregnancy.

How are they treated?

If you do not have
symptoms, you probably do not need treatment.

If your first
gallstone attack causes mild pain, your doctor may tell you to take pain
medicine and wait to see if the pain goes away. You may never have another
attack. Waiting to see what happens usually will not cause problems.

If you have a bad attack, or if you have a second attack, you may want to
have your gallbladder removed. A second attack means you are more likely to
have future attacks.

Many people have their gallbladders removed,
and the surgery usually goes well. Doctors most often use
laparoscopic surgery. For this, your surgeon will make
small cuts in your belly and remove your gallbladder. You will probably be able
to go back to work or your normal routine in a week or two, but it may take
longer for some people. Sometimes the surgeon will have to make a larger cut to
remove the gallbladder. It will take longer for you to recover from this type
of surgery.

Do you need your gallbladder?

Your body will work fine
without a gallbladder. Bile will flow straight from the liver to the intestine.
There may be small changes in how you digest food, but you probably will not
notice them.

Cause

Gallstones
develop when
cholesterol and other substances in the
bile form crystals that become hard stones in the
gallbladder. The gallbladder is a small sac located just under the liver.
Gallstones can occur when your gallbladder does not empty properly or if you
have too much cholesterol in your bile. Too much cholesterol in your bile is
not caused by eating too much cholesterol or having high cholesterol (in the
blood).

Most doctors believe that even microscopic gallstones in
the gallbladder can cause symptoms. These tiny stones can form a type of
sediment called
biliary sludge that often can be seen on an abdominal
ultrasound. For more information on an abdominal ultrasound, see the Exams and
Tests section of this topic.

Symptoms

The most common symptom of
gallstones is pain in the stomach area or in the
upper right part of the belly, under the ribs.

The pain
may:

Start suddenly in the center of the upper
belly (epigastric area) and spread to the right upper back or shoulder blade
area. It is usually hard to get comfortable. Moving around does not make the
pain go away.

Prevent you from taking normal or deep
breaths.

Last 15 minutes to 24 hours. Continuous pain for 1 to 5
hours is common.

Begin at night and be severe enough to wake
you.

Occur after meals.

Gallstone pain can cause vomiting, which may relieve some
of the belly (abdominal) pain and pressure. Pain that occurs with a fever,
nausea, and vomiting or loss of appetite may be a sign of inflammation or
infection of the gallbladder (acute cholecystitis). Symptoms that may mean that
a gallstone is blocking the
common bile duct include:

Yellowing of the skin and the white part of the
eyes (jaundice).

Dark urine.

Light-colored
stools.

A fever and chills.

There are many other conditions that cause similar
symptoms, including heartburn, pain caused by a heart attack, and liver
problems. Stomach flu (gastroenteritis) and food poisoning also can cause
symptoms similar to gallstones. Diarrhea and vomiting occur with the flu and
food poisoning, but the pain tends to come and go rather than be constant.
Also, pain with these conditions may be felt all over the belly, rather than in
one spot.

Belly pain that comes and goes (rather than being
constant) and that occurs with nausea and vomiting and possibly a mild fever is
more likely to be caused by stomach flu or food poisoning than by gallstones.
This is especially true if others around you are sick with similar
symptoms.

What Happens

The progression of
gallstones depends on whether you have symptoms. Most
people with gallstones have no symptoms and do not need treatment. Those who do
have symptoms often have surgery to remove the gallbladder.

Gallstones that do not cause symptoms

Most people
who have gallstones never have symptoms. Most people with gallstones that do
not cause symptoms remain free of symptoms.

Gallstones that cause symptoms

The most common
problem caused by gallstones occurs when a gallstone periodically blocks the
cystic duct, which drains the gallbladder. It often causes bouts of pain that
come and go as the gallbladder contracts and expands. The bouts of pain are
usually severe and steady, lasting from 15 minutes to up to 6 hours. And the
pain may get worse after a meal. Symptoms usually improve within a few days.

If this is your first attack of gallbladder symptoms, your best
option may be to see whether the pain goes away without surgery. But if the
pain is severe or if you have had gallbladder pain before, you may need to have
your gallbladder removed.

Depending on where a stone blocks the
flow of bile, symptoms can include nausea, vomiting, fever, and severe
abdominal pain that lasts longer than 6 hours. If you have these symptoms, you
may need surgery to remove your gallbladder or the gallstone causing the
blockage.

In rare cases, gallstones can cause
pancreatitis, an inflammation of the pancreas.
Gallstones back up the flow of digestive enzymes made by the pancreas.
Pancreatitis may cause sudden, severe abdominal pain, loss of appetite, nausea
and vomiting, and fever.

Do you need surgery or other treatment for your gallstones?

The first attack of gallstone symptoms is often not severe. Serious
complications (such as a blocked duct) rarely occur. So you and your doctor may decide to delay treatment to see whether symptoms go
away on their own. This is especially true if your doctor is not sure that
the symptoms were caused by gallstones. Sometimes surgery for
gallstone problems is needed right away. But in most cases, it appears safe to delay
treatment until you have a second episode of pain. If you have two attacks, you
are likely to have more attacks in the future. In that case, surgery to remove
the gallbladder is usually the best option.

People who have gallstone symptoms are at higher risk of having future
pain and problems than those who do not have symptoms. It is not possible to
predict how often the pain may come back or how severe it might be. Many people
who decide not to have treatment do not have future problems. About 1 out of 3
people with a single attack of pain has no other episode of pain.footnote 1

What Increases Your Risk

Your chances of forming
gallstones that can cause symptoms are higher if
you:

Are female. Females are twice as likely as
males to have gallstones.

Are older than 55.

Are Native American or
Mexican-American.

Have a family history of
gallstones.

You may also be increasing your risk for gallstones if you:

Are overweight.

Lose weight rapidly or lose weight by
dieting and then gain weight back again.

Are pregnant.

Are taking estrogen (after
menopause) or high-dose birth control pills.

Get
very little or no exercise.

Do not eat for a period of time
(fast).

When To Call a Doctor

Abdominal pain can be a sign of
a serious or even life-threatening condition, especially if you have a heart
condition or are older than 60. If you are having sudden or severe pain and are
not sure what is causing it, you may need immediate medical treatment. You
should be especially concerned if you are having trouble breathing or you faint
or lose consciousness. For more information, see the topic
Abdominal Pain, Age 12 and Older. For more information
on abdominal pain in children, see the topic
Abdominal Pain, Age 11 and Younger.

Call your doctor immediately if you have:

Pain that may be caused by
gallstones (continuous moderate to severe pain in the
upper right abdomen) along with a fever of
100.4°F (38°C) or higher and
chills that are clearly not caused by stomach flu or any other
reason.

Pain in the upper midsection or upper right abdomen, along
with a yellow tint to your skin and the white part of your eyes, dark
yellow-brown urine, or light-colored stools.

If you have symptoms of gallstones but no fever, chills, or
yellowing of your skin or the white part of your eyes, you may still require
evaluation and treatment. Schedule an appointment with your doctor.

Watchful waiting

Watchful waiting is a period of time during
which you and your doctor watch your symptoms or condition to see
whether you need treatment. Watchful waiting is often the first approach to a
first attack of gallstone pain.

Who to see

Symptoms caused by gallstones can be
evaluated by any of the following health professionals:

Exams and Tests

Gallstones may
be found during tests that evaluate abdominal pain or during tests for another condition, such as an
ultrasound test during pregnancy. The doctor will ask questions about your medical history and your symptoms. And he or she will do a physical exam. Although your medical history and physical exam
may suggest that you have gallstones, other tests can confirm the diagnosis.

Tests for gallstones

Abdominal ultrasound. An
abdominal ultrasound is the best test to confirm
gallstones. In this test, a technologist moves a wand across your belly to
create pictures on a video monitor. This test may reveal other problems with
the
gallbladder or bile ducts. An
ultrasound image of a gallstone often is the only test needed to find and
evaluate gallstones.

Gallbladder scan. If your gallbladder looks normal on an abdominal ultrasound, but
your doctor still thinks that you may have a problem, your doctor may request a
gallbladder scan. In this test, a doctor injects
a special radioactive dye into a vein in your arm and takes pictures to see
whether the gallbladder is working normally. This test can also reveal other
problems, such as blocked bile ducts (bile ducts are tubes attached to your
gallbladder).

Endoscopic retrograde cholangiopancreatogram (ERCP). This test is used if your doctor thinks
that you may have a gallstone in one of the ducts that connect your liver with
your gallbladder, pancreas, and small intestine. In an
ERCP, a doctor gently moves a flexible, lighted
viewing instrument called an endoscope down the throat and through your stomach
to examine the tubes that drain your liver, gallbladder, and pancreas. If a
gallstone is blocking your
common bile duct, the doctor can sometimes remove the
stone with instruments inserted through the endoscope.

Blood tests

Blood tests. Tests such as a
complete blood count and tests for liver function and
pancreatitis can help a doctor evaluate symptoms of abdominal pain
that may be caused by gallstones. The tests may be able to detect whether your
symptoms are being caused by a condition other than gallstones.

Other tests

Endoscopic ultrasound (EUS). This test can be used to see
gallstones in the common bile duct. A doctor gently moves a thin, flexible,
lighted viewing instrument (endoscope) with an ultrasound probe down the throat
and through your stomach to examine the tubes that drain the liver,
gallbladder, and pancreas.

Magnetic resonance cholangiogram (MRC). This test uses a magnetic field and pulses of radio
wave energy (MRI) to provide pictures of organs and structures inside the
belly. Doctors can use an
MRC to locate gallstones before surgery to remove the
gallbladder or to detect problems with the bile
duct or gallbladder.

Treatment Overview

If
gallstones don't cause pain or other symptoms, you
most likely will not need treatment. In rare cases, doctors may advise surgery
for gallstones that don't cause symptoms.

If gallstones do cause symptoms, you and
your doctor may decide that your best choice is to see whether symptoms go away
on their own (watchful waiting). It is usually safe to wait until you have had
another attack before you consider having surgery. Watchful waiting may be the
best choice if:

This is your first episode of gallstone
pain.

Gallstone pain is mild. If your gallstones cause severe
pain, surgery may be considered to prevent future attacks and
possible complications.

If you need treatment for gallstones, in most cases the
best treatment is surgery to remove the gallbladder (cholecystectomy). In many
cases,
laparoscopic surgery is the best method to remove the
gallbladder. Open surgery requires a longer recovery period and causes more
pain because it creates a larger incision.

Your doctor can help
you assess the severity of your gallstone attacks and can help you decide
whether you should have surgery or other treatment.

Prevention

There is no sure way to prevent
gallstones. But you can reduce your risk of forming
gallstones that can cause symptoms.

Maintain a healthy weight

Stay close to
a healthy weight. If you need to lose weight, do so slowly and sensibly. When
you lose weight by dieting and then you gain weight back again, you increase
your risk for gallstones, especially if you are a woman. If you diet, aim for
a weight loss of only
1 lb (0.5 kg) to
1.5 lb (0.7 kg) a week. For
more information, see the topic
Weight Management.

Eat regular, balanced meals

Try not to
skip meals. Eat on a regular schedule. And eat meals that contain some fat (which causes the
gallbladder to empty). This can help prevent gallstones. Eat plenty of whole
grains and fiber. And be sure to often have servings of foods that contain calcium (milk products and green, leafy vegetables). Limit saturated (animal) fat.

Exercise regularly

If you exercise more, you may be able to reduce your risk for gallstones. Along with eating a healthy diet, exercise is an effective way
to help you stay close to a healthy weight and lower your
cholesterol and
triglyceride levels.

Deciding whether to take estrogen

Some evidence
shows that taking hormones such as
estrogen after menopause or taking high-dose birth
control pills may increase a woman's risk of gallstones that cause
symptoms. If you are taking such hormones, talk with your doctor.

Home Treatment

There is no specific home treatment
for
gallstones, but be sure to call your doctor
if:

You think you have symptoms that may be caused
by gallstones. If your doctor finds that you do have gallstones but your
symptoms are mild, it is generally safe to wait until you have more than one
attack before you consider having surgery.

You develop symptoms of
a gallstone attack again, especially if they are severe or occur with fever,
chills, or yellowing of your skin or the white part of your
eyes.

You have new belly pain or other belly symptoms. Pain in the
belly can be a symptom of many health problems.

You may be able to help prevent gallstones if:

You stay close to a healthy weight by eating a
balanced diet and getting regular exercise.

You avoid rapid weight
loss. Intentional weight loss (dieting, as opposed to weight loss from illness)
followed by weight gain may increase your risk of gallstones,
especially if you are a woman. If you need to lose weight, do so slowly and
sensibly.

If you have recently had surgery to remove your
gallbladder:

Watch for signs of infection. Call your doctor
if the area around the incision is red and puffy or if you have a
fever.

Call your doctor if you have yellowing of the skin or the
white part of the eyes (jaundice), light-colored stools, and dark urine. These
symptoms may be signs that gallstones are blocking the
common bile duct.

Medications

Medicines are rarely used to treat
gallstones.

Medicine choices

Bile acids can be used to dissolve gallstones. They
usually are reserved for people who have symptoms of gallstones and for whom surgery
would be risky.

What to think about

Gallstones often come back when
treatment with bile acids is stopped. Over time, gallstones return in about half of those who stop
taking the medicine.footnote 2

This form of
treatment works better on small gallstones than on large ones. It does not work
on calcified gallstones. Tests such as an
abdominal X-ray may be used to find out whether
gallstones contain calcium.

Surgery choices

Laparoscopic gallbladder surgery is
the most common surgery done to remove the gallbladder. In this type of
surgery, a doctor inserts a lighted viewing instrument called a laparoscope and
surgical tools into your abdomen through several small cuts (incisions). This
type of surgery is very safe, and people who have it usually recover enough in
about one week to go back to work or to their normal
routines.

Open gallbladder surgery involves one larger incision through which the gallbladder is
removed. It may be done if laparoscopic surgery is not an option or when
complications are found during laparoscopic surgery. Most open surgeries occur
after trying to do a laparoscopic cholecystectomy. Open surgery also may be the
best choice if the blood won't clot well, the anatomy is not normal, or there
is too much scarring from previous surgery.

Other Treatment

Other treatment options for
gallstones are not widely available. Less is known
about their effectiveness and long-term impact compared with surgery.

Other treatment choices

Other treatments for gallstones in the common bile duct
include:

Endoscopic retrograde cholangiopancreatogram (ERCP) with endoscopic sphincterotomy.
In an ERCP, a doctor gently moves a flexible, lighted viewing instrument (endoscope) down your throat and through your stomach
to examine the tubes that drain your liver and gallbladder. If you have a
gallstone in the common bile duct, the gallstone can sometimes be removed
through the endoscope.

Other treatments for gallstones in the gallbladder
include:

Lithotripsy. This procedure uses
ultrasound waves to break up gallstones. It may be used alone or along with
bile acids to break up stones. The procedure, which is now rarely performed,
has been used for people who have long-term (chronic) inflammation of the
gallbladder (cholecystitis) and who are not strong enough for surgery. But it
is not appropriate in treating sudden (acute)
cholecystitis.

Contact dissolution therapy. This treatment uses a
thin, flexible tube called a catheter to place a chemical in the gallbladder to
dissolve gallstones. This therapy is rarely used because of the risk of
complications. And unlike with surgery, gallstones may return.

Percutaneous cholecystostomy. This procedure may provide
temporary relief for an inflamed gallbladder until an endoscopic retrograde
cholangiopancreatogram (ERCP) or surgery can be performed. During percutaneous
cholecystostomy, a doctor places a tube through the abdomen and into the
gallbladder to drain its contents. This sometimes is done for people who are
not strong enough for surgery.

Other Places To Get Help

Organization

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) (U.S.)

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